Vascular Diseases of the Spinal Cord: Infarction, Hemorrhage, and Venous Congestive Myelopathy

Sildenafil-induced spinal cord infarction: a case report

Spinal cord infarction is a rare condition, accounting for only a small percentage of strokes. It can be classified into cervical and thoracolumbar infarctions, with various factors contributing to its occurrence. Sildenafil, a phosphodiesterase type 5 inhibitor commonly used for erectile dysfunction, has been associated with cardiovascular side effects, including transient hypotension. In this case report, we present the unusual occurrence of spinal cord infarction in a 65-year-old man who had self-administered high doses of sildenafil without a doctor's prescription. The patient experienced severe radicular pain in the lumbar region and subsequent weakness in the lower limbs. Evaluation revealed an anterior spinal cord infarction in the thoracic region, confirmed by MRI imaging. After excluding other potential causes, it was concluded that the intake of sildenafil likely led to systemic hypotension, resulting in spinal cord infarction. This case highlights the importance of considering sildenafil as a possible contributor to spinal cord infarction, particularly when used at high doses. Further studies are needed to better understand the relationship between sildenafil and vascular complications, including spinal cord infarction.

Severe Mimic of Transverse Myelitis - Spontaneous Non-Traumatic Intramedullary Hematomyelia: A Case Report

Spinal cord hemorrhage remains an uncommon vascular pathology with no standard approach to treatment. Intramedullary hematomyelia is the rarest subtype and has only been described in case reports, making it a diagnosis easier to miss. A 55-year-old male with history of polysubstance abuse presented for abrupt onset non-traumatic back pain that progressed over several days evolving into paraplegia, sensory loss up to the T3 dermatome, and incontinence of bowel and bladder. His MRI imaging of the cervical and thoracic spine was concerning for a T1 and T2 hyperintense lesion extending from the internal medulla to the upper thoracic spine causing edema. The initial differential diagnosis, based on history and progressive neurologic decline, included a longitudinally extensive transverse mellitus of unclear etiology. He received high dose steroids and plasma exchange without any clinical improvement. An extensive autoimmune, inflammatory, infectious, and demyelinating workup via serum and CSF analysis was unremarkable. He was transferred to a tertiary facility, where repeat MRI spinal imaging included GRE sequences that was significant for increased susceptibility. MRA imaging of the spine was completed showing no vascular malformation. Overall, the diagnosis of hematomyelia was felt to be most likely. Despite aggressive inpatient rehabilitation, the patient remains paraplegic and requires long term management consistent with severe spinal cord injury. This case highlights the importance of recognizing vascular syndromes as a cause of acute myelopathy, understanding the imaging findings of blood breakdown products on MRI, and the desperate need for successful therapeutic strategies to combat a potentially devastating neurologic process.

Clinical and prognostic features of venous hypertensive myelopathy from craniocervical arteriovenous fistulas: a retrospective cohort study

OBJECTIVE

Current knowledge about venous hypertensive myelopathy (VHM) is incomplete. This study was performed with the aim of clarifying the clinical features and outcomes of craniocervical VHM.

METHODS

This retrospective, single-center cohort study included 65 patients with craniocervical junction arteriovenous fistulas resulting in VHM treated in Xuanwu Hospital from January 1, 2002, to December 30, 2020. All patients underwent microsurgery or endovascular treatment. The primary outcome was neurological function assessment using the Japanese Orthopaedic Association (JOA) scale, modified Aminoff-Logue Scale (mALS), and Venous Hypertensive Myelopathy Scale (VHMS). The secondary outcomes were recurrences and postoperative adverse events. Pearson linear regression and receiver operating characteristic curves were used to evaluate the relationships among the three scales. Kaplan-Meier and multivariate logistic regression analyses were performed to predict outcomes.

RESULTS

The mean patient age was 57.4 ± 11.4 years, and 88% of patients were male. The 1-year follow-up rate was 83.1%, and the 5-year follow-up rate was 50.8%. The VHMS was correlated with the JOA (R2 = 0.6722) and mALS (R2 = 0.7399) and increased the assessment accuracy by approximately 20% when compared with the other two scales. Overall, 25.9% of patients experienced delayed neurological decline beyond the 1-year follow-up. Further logistic regression suggested that age > 65 years was an independent predictor (OR 7.831, 95% CI 1.090-56.266; p = 0.041). Embolic recanalization and new bilateral symmetry feeders were the major reasons for recurrence. Recurrence increased the risk of adverse events after the second surgery (OR 20.455, 95% CI 1.170-357.320; p = 0.039).

CONCLUSIONS

CCJ AVFs resulting in VHM are a rare but deadly complication, and providers should be cautious of age-related delayed neurological decline and strive for a one-time anatomical cure.

Potential biomarkers of spinal dural arteriovenous fistula: C4BPA and C1QA

Background and purpose

A major challenge in spinal dural arteriovenous fistula (SDAVF) is timely diagnosis, but no specific predictive biomarkers are known.

Methods

In the discovery cohort (case, n = 8 vs. control, n = 8), we used cerebrospinal fluid (CSF) and paired plasma samples to identify differentially expressed proteins by label-free quantitative proteomics. Further bioinformatics enrichment analyses were performed to screen target proteins. Finally, it was validated by ELISA in two of the new cohorts (case, n = 17 vs. control, n = 9), and univariate analysis, simple linear regression, and receiver operator characteristic (ROC) curve analysis were performed to evaluate the diagnostic potential.

Results

In the discovery cohort, the most overexpressed proteins were APOB and C4BPA in CSF samples of patients. The GO/KEGG enrichment analysis indicated that the upregulated proteins were mainly involved in the acute inflammatory response and complement activation. Hub-gene analysis revealed that APP might be the key protein in the molecular interaction network. In the validation cohort, C4BPA and C1QA were significantly overexpressed in the CSF of patients, averaging 3046.9 ng/ml and 2167.2 ng/ml, respectively. Simple linear regression demonstrated that levels of C1QA and C4 were positively correlated with total protein in CSF (R² = 0.8021, p = 0.0005; R² = 0.7447, p = 0.0013). The areas under the ROC curves of C4BPA and C1QA were 0.86 and 1.00, respectively.

Conclusions

This study was the first to identify C4BPA and C1QA as potential biomarkers for the diagnosis of SDAVF and revealed that complement pathway activation might be one of the molecular mechanisms for venous hypertension myelopathy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02522-x.

Spinal Vascular Shunts: A Patterned Approach

Spinal vascular shunts, including fistulas and malformations, are rare and complex vascular lesions for which multiple classification schemes have been proposed. The most widely adopted scheme consists of 4 types: type I, dural AVFs; type II, intramedullary glomus AVMs; type III, juvenile/metameric AVMs; and type IV, intradural perimedullary AVFs. MR imaging and angiography techniques permit detailed assessment of spinal arteriovenous shunts, though DSA is the criterion standard for delineating vascular anatomy and treatment planning. Diagnosis is almost exclusively based on imaging, and features often mimic more common pathologies. The radiologist's recognition of spinal vascular shunts may improve outcomes because patients may benefit from early intervention.

Acute spinal cord infarction after multilevel en bloc corpectomy: a case report and literature review

Spinal cord infarction (SCI) is a catastrophic neurologic deficit following spine surgery. Because of the opposite management regimens used for SCI and acute epidural hematoma, accurate diagnosis of SCI is of great importance to maximally reserve neurologic functions and improve outcomes. A 21-year-old man developed acute paralysis and sensory deficits of the bilateral lower limbs shortly after undergoing two-stage combined posterior and anterior multilevel en bloc corpectomy. An emergency second-look surgery revealed wide-spectrum blackness of the thecal sac with no signs of an epidural hematoma. The patient underwent anticoagulation therapy, ventilation support, microcirculation perfusion, and fluid optimization. He regained an ambulatory status without other severe complications. Upon discharge, his muscle strength had returned to grade 4 and his Eastern Cooperative Oncology Group performance score had decreased to 0. At the final 48-month follow-up, the implants were in good position without local recurrence, and the patient was able to lead an independent life and work in his full capacity. An epidural hematoma did not appear to be the cause of SCI after spinal tumor surgery in this case; however, SCI was a possible reason for the acute paralysis. Anticoagulation treatment with adjuvant therapies may be an effective option in managing SCI.

Anatomical structures, cell types and biomarkers of the Human Reference Atlas

The Human Reference Atlas (HRA) aims to map all of the cells of the human body to advance biomedical research and clinical practice. This Perspective presents collaborative work by members of 16 international consortia on two essential and interlinked parts of the HRA: (1) three-dimensional representations of anatomy that are linked to (2) tables that name and interlink major anatomical structures, cell types, plus biomarkers (ASCT+B). We discuss four examples that demonstrate the practical utility of the HRA.

Spinal vascular lesions: anatomy, imaging techniques and treatment

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Vascular myelopathies include different aetiology and mechanism of damage.

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The level of the lesion and the localization within the SC correlates with the clinical symptoms.

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CT, MRI and angiography are essential for diagnosis and treatment playing a complementary role.

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MRI is the gold standard for the evaluation of spinal cord lesions.

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Spinal angiography is the gold standard for evaluation of spinal cord vasculature and vascular malformations.

Background

Vascular lesions of the spinal cord are rare but potentially devastating conditions whose accurate recognition critically determines the clinical outcome. Several conditions lead to myelopathy due to either arterial ischemia, venous congestion or bleeding within the cord. The clinical presentation varies, according with the different aetiology and mechanism of damage.

Purpose

The aim is to provide a comprehensive review on the radiological features of the most common vascular myelopathies, passing through the knowledge of the vascular spinal anatomy and the clinical aspects of the different aetiologies, which is crucial to promptly address the diagnosis and the radiological assessment.

ACR Appropriateness Criteria® Myelopathy: 2021 Update

Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vascular Myelopathies

PURPOSE OF REVIEW

Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy.

RECENT FINDINGS

Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage.

SUMMARY

It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.

Prediction of outcome following laminoplasty of cervical spondylotic myelopathy: Focus on the minimum clinically important difference

The minimum clinically important difference (MCID) of the Japanese Orthopaedic Association (JOA) score has been reported to be around 2.5 points in cervical myelopathy. This study sought to define significant predictive factors on achieving the MCID following laminoplasty in a large series of patients with cervical spondylotic myelopathy (CSM). A total of 485 consecutive patients with CSM (295 males and 190 females; mean age: 67.0 years; age range: 42-91 years) who underwent laminoplasty were prospectively enrolled. The average postoperative follow-up period was 26.6 months (range: 12-66 months). We calculated the achieved JOA score. The relationships between outcomes and various clinical and imaging predictors including comorbidity and quantitative performance tests were examined. Logistic regression analysis was conducted to identify the predictors correlated with a JOA score of 2.5 points or more. Clinically meaningful gains were exhibited in 299 patients (61.6%) with a JOA score of ≥2.5 points, whereas 186 patients (38.4%) achieved a JOA score of <2.5 points. Univariate logistic regression analysis showed the predictive factors with a shorter duration of CSM symptoms, lower preoperative JOA scores, absence of hypertension, no use of anticoagulant/antiplatelet agents, and nonsmoking status. Multivariate logistic regression analysis determined that the duration of CSM symptoms (odds ratio: 0.771, 95% confidence interval: 0.705-0.844; p < 0.01) was the only significant predictive factor for achieving JOA scores of ≥2.5 points. An important predictor of MCID achievement following laminoplasty was shorter duration of CSM symptoms.

Etiology and Outcomes of Spinal Cord Infarct: A Case Series From a Level 1 Trauma Center

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the demographics, prevalence, etiology, severity, and outcomes of spinal cord injuries (SCIs) resulting from ischemic infarction.

METHODS

All patients with SCI and a diagnosis of cord infarct who were admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were identified using an administrative billing database. Outcomes measures were evaluated.

RESULTS

Among 685 unique SCI patients who were identified, 30 (4.4%) had SCI due to spinal ischemic infarction. The mean age was 59 years (range 17-80 years). Fifty percent of patients had ASIA (American Spinal Injury Association) A and B severity. Most common causes were the following: 6 (20%) abdominal aortic aneurysm (AAA) repairs, 6 (20%) arteriovenous fistulas, and 6 (20%) with an unknown cause. Surgical complications led to 4 (13.3%) cord infarcts and was associated with a higher severity of injury (P = .02) compared with other etiologies. Other causes included systemic hypotension, AAA rupture, trauma, diabetic ketoacidosis, and after radiation therapy. At follow-up, 6 (20%) of patients were able to ambulate normally without assistance, 7 (23.3%) were ambulating with assistance, and 17 (56.7%) were still wheelchair bound. Clinical improvement in ambulatory status was noted in 6 (20%) patients and was associated with less severe initial injury (P = .02).

CONCLUSIONS

While the existing literature associates spinal cord infarction with aortic pathologies and surgery, these caused less than 30% of cases, while nonaortic surgical complications were associated with the most severe injuries. Outcomes were worse than previously reported in the literature.

Spinal cord infarction associated to retinal vein occlusion in a patient with chronic kidney disease

A 70-year-old man presented to the emergency department with blood hypotension associated to a sudden paraplegia and thermalgesic analgesia. He had an history of colic and prostatic adenocarcinoma, hypertension and non-dialyzed Chronic Kidney Disease (CKD) related to an idiopathic membranous glomerulonephritis type 1 discovered 9 years ago. Magnetic resonance imaging confirmed a diagnosis of Spinal Cord Infarction (SCI). Few months later, he presented a blurred vision due to central Retinal Vein Occlusion (RVO), which was improved by Anti-VEGF therapy. This is the first reported case of a concomitance of retinal vascular event and SCI highlights the links between the central nervous system and retinal vascularization despite separate involvement of the two events in the arterial and venous systems. Additionally, CKD worsened the risk of cardiovascular incidents by induced oxidative stress, thrombophilia, chronic inflammation, and endothelial dysfunction. SCI occurrence indicates severe vascular dysfunction and elevates the risk of additional vascular disorders.

Canine Snake-Eye Myelopathy: Clinical, Magnetic Resonance Imaging, and Pathologic Findings in Four Cases

Intramedullary signal change (ISC) is a non-specific finding that is frequently observed on magnetic resonance imaging (MRI) examinations of the canine spinal cord. ISC can represent a variety of primary pathological processes such as neoplasms or myelitides or secondary changes such as edema, cysts, gliosis, or myelomalacia. An unusual phenotype of ISC is the “snake-eye” myelopathy (SEM), which refers to bilaterally symmetric T2 hyperintensities preferentially affecting the ventral horn gray matter on transverse MR images, which resemble a pair of snake's eyes. The pathophysiology of SEM is poorly understood in humans, and this imaging finding may be associated with cervical spondylotic myelopathy, spinal cord ischemia, ossification of the posterior longitudinal ligament, amyotrophic lateral sclerosis, and Hirayama disease. Here we describe four dogs with cervical MRI examinations consistent with an SEM-like phenotype. All dogs initially presented with a central cord syndrome or tetraparesis referable to a C6-T2 neuroanatomic localization, which was attributed to disc-associated spinal cord compression in three cases, while one dog had the SEM-like phenotype with no identifiable etiology. Once the SEM-like phenotype was present on MRI examinations, dogs demonstrated insidious clinical deterioration despite therapeutic interventions. Deterioration was characterized by lower motor neuron weakness and neurogenic muscle atrophy progressing to paralysis in the thoracic limbs, while neurological functions caudal to the level of the SEM-like lesion remained largely preserved for months to years thereafter. Neuropathological features of the SEM-like phenotype include multisegmental cavitations and poliomyelomalacia of laminae VI-IX of the caudal cervical spinal cord, although the lesion evolved into pan-necrosis of gray matter with extension into the adjacent white matter in one case with an 8 years history of progressive disease. Although the pathophysiology of SEM remains unknown, the topographical distribution and appearance of lesions is suggestive of a vascular disorder. As the SEM-like phenotype was uniformly characterized by longitudinally and circumferentially extensive neuronal necrosis, results of this small case series indicate that dogs with clinical signs of central cord syndrome and the SEM-like phenotype involving the cervicothoracic intumescence on MR examinations have a poor prognosis for the preservation or recovery of thoracic limb motor function.

The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study

AIM

Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH.

MATERIAL AND METHODS

Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed.

RESULTS

The average degenerated soma intensity/mm³ at the C5-6 levels in the spinal cord was 2 ± 1/mm³, 13 ± 4/mm³, and 56 ± 10/mm³ for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm², 34 ± 9/mm², and 234 ± 78/mm² for Groups I, II, and III.

CONCLUSION

Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.

A practical approach to the diagnosis of spinal cord lesions

Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.

Vascular spinal cord obstruction associated with superior vena cava syndrome: A case report and literature review

RATIONALE

Superior vena cava syndrome (SVCS) is the obstruction of blood flow through the SVC, causing complete or partial blockade of the collateral circulation of returning venous blood. SVCS is frequently presented with facial, neck, trunk, and upper limbs swelling and so on. However, to the best of our knowledge, the obstruction of the venous return in the spinal veins is rarely a manifestation of SVCS.

PATIENT CONCERNS

We presented a rare case of a 52-year-old male patient with 2-month history of progressive right upper limb numbness and swelling and 10-day history of extremities malfunctioning. Cervical magnetic resonance imaging (MRI) detected obstruction of the spinal venous return. Lung computed tomography (CT) revealed lesions in the esophagus, which indicated esophageal cancer with mediastinal lymph nodes metastasis and signified SVCS.

DIAGNOSES

With the results of laboratory findings, cervical MRI, lung CT findings, and physical examination, the patient was diagnosed with SVCS manifesting as spinal vein obstruction.

INTERVENTIONS AND OUTCOMES

The family abandoned further treatment, and the patient passed away 2 months after discharge.

LESSONS

The case indicates that SVCS can induce systemic and spinal cord diseases affecting the venous return. Further studies are necessary to reveal the mechanism for SVCS inducing spinal veins obstruction and to explore whether SVCS patients with and without vascular spinal cord obstruction have different prognoses.

Magnetic Resonance Imaging and Clinical Features in Acute and Subacute Myelopathies

Differential diagnosis of acute and subacute transverse myelopathy includes inflammatory, infectious, vascular, metabolic and paraneoplastic etiologies. Information on the diagnostic approach to transverse myelopathy with regard to daily clinical practice is provided. The differentiation between five lesion patterns on magnetic resonance imaging (MRI) in myelitis may be helpful: (1) longitudinal extensive transverse myelitis, (2) short segment ovoid or peripherally located, (3) "polio-like", (4) granulomatous and (5) segmental with rash. A correlation with these imaging features is supported if the clinical course and neurological symptoms are known. Although the mean interval from onset to nadir of symptoms in spinal cord infarction is 1 h, an overlap with a fulminant course of myelitis is possible, and impaired diffusion may also occur in acute inflammatory processes. As a result, laboratory testing, including aquaporin-4 antibodies and cerebrospinal fluid analysis, is crucial for the correct interpretation of imaging findings. Moreover, the discrimination of acute complete and acute partial transverse myelitis is advantageous in order to identify diverse entities, the latter often being a precursor to multiple sclerosis. Additional brain imaging is mandatory in suspected demyelinating, infectious, neoplastic and systemic autoimmune disease. A symmetrical lesion pattern restricted to individual tracts or dorsal columns indicates subacute combined degeneration of the spinal cord and, in addition to deficiency syndromes, a paraneoplastic etiology should be considered.