Long-term outcome after spinal cord infarctions

Spontaneous spinal cord infarction: a systematic review

Background and objectives

Spontaneous 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. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes.

Methods

The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed.

Results

440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids.

Conclusion

The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol

INTRODUCTION

Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied.

METHODS AND ANALYSIS

Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts.

ETHICS AND DISSEMINATION

Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.

Spontaneous spinal cord infarction: a practical approach

Spontaneous spinal cord infarction is significantly less common than cerebrovascular disease. Because of the tight anatomical distribution of pathways in the cord, small spinal cord infarcts usually give more obvious symptoms and signs than similar lesions in the brain. Large epidemiological stroke studies have generally not included spinal cord stroke and so the incidence of vascular syndromes in the spinal cord is unknown. Management and prevention strategies for spontaneous spinal cord infarcts stem from small case series and case reports. Patient outcomes from spinal cord infarction are better with prompt recognition, timely management and prevention of associated medical complications arising from paraplegia, tetraplegia, neurogenic bladder and bowel dysfunction. The process of rehabilitation following spinal cord infarction is an evolving area.

Spinal cord infarction complicating acute aortic syndrome: about 2 cases

Spinal cord infarction is an uncommon but devastating disorder caused by various conditions. It remains however a rare neurological complication in acute aortic injuries. In this context, aortic dissection is the most frequent etiological factor. Acute aortic intra mural hematoma and atheromatous penetrating ulcer remain exceptional. We encountered two cases of spinal cord infarction associated with acute aortic intra mural hematoma in one case and atheromatous penetrating ulcer in the other case that presented without typical severe pain. Thus, acute aortic injuries should be considered a cause of spinal cord infarction even if there is little or no pain.

Acute Myelopathy in Childhood

Acute myelopathy presenting in childhood can be clinically classified based on the location of injury (with resulting spinal syndrome) or the cause (broadly traumatic or non-traumatic). Types of nontraumatic myelopathy include ischaemic, infectious, inflammatory, nutritional, and metabolic causes, some of which may be part of a systemic illness such as systemic lupus erythematosus or a demyelinating disease such as multiple sclerosis. Nonaccidental injury is an important consideration in cases of traumatic myelopathy, which may often be associated with other injuries. Assessment should include neuroimaging of the brain and spinal cord, with further investigations targeted based on the most likely differential diagnoses; for example, a child with suspected demyelinating disease may require specialist cerebrospinal fluid and serological testing. Management also will differ based on the cause of the myelopathy, with several of these treatments more efficacious with earlier initiation, necessitating prompt recognition, diagnosis, and treatment of children presenting with symptoms of a myelopathy. Important components of holistic care may include physiotherapy and occupational therapy, with multidisciplinary team involvement as required (for example psychological support or specialist bowel and bladder teams).

Tat-p27 Ameliorates Neuronal Damage Reducing α-Synuclein and Inflammatory Responses in Motor Neurons After Spinal Cord Ischemia

p27^Kip1 (p27) regulates the cell cycle by inhibiting G1 progression in cells. Several studies have shown conflicting results on the effects of p27 against cell death in various insults. In the present study, we examined the neuroprotective effects of p27 against H₂O₂-induced oxidative stress in NSC34 cells and against spinal cord ischemia-induced neuronal damage in rabbits. To promote delivery into NSC34 cells and motor neurons in the spinal cord, Tat-p27 fusion protein and its control protein (Control-p27) were synthesized with or without Tat peptide, respectively. Tat-p27, but not Control-27, was efficiently introduced into NSC34 cells in a concentration- and time-dependent manner, and the protein was detected in the cytoplasm. Tat-p27 showed neuroprotective effects against oxidative stress induced by H₂O₂ treatment and reduced the formation of reactive oxygen species, DNA fragmentation, and lipid peroxidation in NSC34 cells. Tat-p27, but not Control-p27, ameliorated ischemia-induced neurological deficits and cell damage in the rabbit spinal cord. In addition, Tat-p27 treatment reduced the expression of α-synuclein, activation of microglia, and release of pro-inflammatory cytokines such as interleukin-1β and tumor necrosis factor-α in the spinal cord. Taken together, these results suggest that Tat-p27 inhibits neuronal damage by decreasing oxidative stress, α-synuclein expression, and inflammatory responses after ischemia.

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.

Interdisciplinary, Intensive, Activity-Based Treatment for Intrauterine Spinal Cord Infarct: A Case Report

Intrauterine spinal cord infarcts (IUSCI) with resulting tetraplegia are extremely rare, and there is minimal evidence describing outcomes in this population. This case describes the functional progress of a 3-year-old girl born with IUSCI who participated in activity-based therapies (ABT). Children have developing nervous systems and are particularly suited to benefit from ABT. Over the course of treatment, the child in this case has demonstrated improvements in developmental milestone achievement including fine and gross motor skills and social/cognitive development. Intense, interdisciplinary ABT should be considered for the treatment of children with IUSCI.

Spinal Cord Infarction with Aortic Dissection

Spinal cord infarction is an uncommon but devastating disorder caused by various conditions. Aortic dissection is a possible etiological factor and is usually associated with severe chest or back pain. We encountered two cases of spinal cord infarction associated with aortic dissection that presented without typical severe pain, and each case resulted in a different clinical course. Aortic dissection should be considered a cause of spinal cord infarction even if there is little or no pain. The different outcomes in our two patients reflected a difference in their initial functional scores.

Atypical spinal cord infarction: A case report

INTRODUCTION

The abrupt onset of sensorimotor deficits is a neurologic emergency that requires immediate management. Acute spontaneous spinal cord infarction (SCI) is rare, but can cause the sudden onset of quadriplegia or quadriparesis. Magnetic resonance imaging (MRI) is an essential imaging modality to diagnose SCI.

CASE PRESENTATION

A 75-year-old man with a history of diabetes mellitus type 2, hypertension, and dyslipidemia was transferred to our facility for further workup of the sudden onset of quadriplegia. Diffusion-weighted contrast MRI (DWI) on hospital day 8 revealed hyperintense signals predominantly at the grey matter, and a contrast T2 signal abnormality with a decreased apparent diffusion coefficient (ADC). Steroid pulse therapy was initiated because myelitis could not be completely ruled out, but this did not improve the neurological deficits. Spontaneous SCI was finally diagnosed as an exclusion diagnosis. Symptoms were gradually recovered with rehabilitation, and he was transferred to a rehabilitation facility on hospital day 40.

CONCLUSION

MRI with DWI of the spine should be considered for an early diagnosis of SCI. A combination of DWI with ADC maps is recommended to distinguish SCI from other differential disorders.

Spinal Cord Infarcts: Risk Factors, Management, and Prognosis

OPINION STATEMENT

There are no standard guidelines for treatment of spinal cord ischemia due to how rare it is and the diverse etiology and presentations involved. In addition, to date, there have been no large clinical trials examining ideal pharmacologic treatment options for spinal cord infarct. In our practice, we rely on hemodynamic augmentation initiated as soon as possible. Otherwise, treatment is usually geared towards the etiology of spinal cord ischemia. For instance, spinal cord ischemia occurring after aortic aneurysmal repair may improve with CSF drainage through a lumbar catheter in the periprocedural setting. Vertebral artery dissection should be treated with antithrombotics. If no clear etiology is found and there is evidence of atherosclerosis in other vascular beds, then management is focused on risk factor modification with blood pressure and glucose control, statins, and antithrombotics.

Delayed Hospital Presentation and Neuroimaging in Non-surgical Spinal Cord Infarction

BACKGROUND

Lack of timely recognition and neuroimaging may be a barrier to reperfusion efforts in acute spinal cord infarction.

METHODS

We performed a retrospective study of patients diagnosed with acute non-surgical spinal cord infarction at our tertiary academic center from 2001 to 2015. We studied parameters associated with time from symptom onset to initial hospital presentation and magnetic resonance imaging (MRI) of the spinal cord.

RESULTS

We identified 39 patients among whom anterior spinal artery syndrome was the most frequent presentation (87.2%) and atherosclerosis the most common etiology (56.4%). Nearly, half of the patients presented to the emergency department on the same day of symptom onset (48.7%) but only nine (23.1%) within the first 6 h. Average time from symptom onset to spinal cord MRI was 3.2 days. We could not identify clinical, radiological, or outcome patterns associated with early vs. delayed presentation and imaging.

DISCUSSION

Our study found a time lag from symptom onset to hospital presentation and spinal cord MRI in patients with acute spinal cord infarction. These findings point at low clinical suspicion of spinal cord syndromes and limited recognition as a potentially treatable medical emergency.

Current and emerging treatment options for spinal cord ischemia

Spinal cord infarction (SCI) is a rare but disabling disorder caused by a wide spectrum of conditions. Given the lack of randomized-controlled trials, contemporary treatment concepts are adapted from guidelines for cerebral ischemia, atherosclerotic vascular disease, and acute traumatic spinal cord injury. In addition, patients with SCI are at risk for several potentially life-threatening but preventable systemic and neurologic complications. Notably, there is emerging evidence from preclinical studies for the use of neuroprotection in acute ischemic injury of the spinal cord. In this review, we discuss the current state of the art for the therapy and prevention of SCI and highlight potential emerging treatment concepts awaiting translational adoption.