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

Systemic intravenous thrombolysis and spinal stroke: a case report and review of the literature

Background

Spinal cord infarction (SCI) is associated with poor clinical outcome. Intravenous thrombolysis (IVT) is a well-established treatment for cerebral ischaemic stroke. However, its efficacy in SCI is unknown.

Objective

We present a case of acute spinal cord ischaemia with significant improvement following thrombolysis and review the current literature to explore the safety and feasibility of this treatment.

Methods

We reviewed the literature for cases of SCI that were treated with IVT. We reviewed their medical history, clinical presentation and the reported outcome.

Results

Other than our case, our review includes 19 cases of SCI treated with IVT. Their mean age was 62.87±15.27 and 36% of them were women. Most of the cases were spontaneous and treated within 240 min of onset. Favourable outcome was achieved in 89% of cases, including the few cases treated within extended time window. No clinical worsening due to haemorrhage was reported in either case.

Conclusions

IVT may be considered in certain settings as treatment for SCI following the appropriate work-up. Favourable outcome was achieved in most cases and no case experienced clinical worsening due to post-thrombolysis haemorrhage. Safety and efficacy of this approach need further investigation.

Non-surgical spinal cord infarction: case series & long-term follow-up of functional outcome

INTRODUCTION

Spinal cord infarction is a rare but often devastating disorder. The pathogenesis of most non-surgical cases involves atherothrombosis and treatment with anticoagulation and antiplatelet agents may be indicated. Functional recovery in most cases is poor. We describe five cases of spinal cord infarction and provide details on their functional outcomes after long-term (>10 years) follow-up.

CASE PRESENTATION

A 28-year-old female presented at 16 weeks gestation with chest and back pain and paraesthesia in her fingers. Magnetic resonance imaging on admission revealed a spinal cord lesion extending from C5-T8. She was treated with anticoagulation and rehabilitation. Six years following presentation she was able to return to work. A 42-year-old male experiencing central chest pain and leg weakness was initially diagnosed as having acute coronary syndrome. Following discharge, he was re-admitted with urinary retention and leg weakness. Magnetic resonance imaging revealed a spinal cord lesion extending from T4 to T7. He was treated with anticoagulation, and eight months following presentation he regained full muscle strength but required intermittent self-catherisation. Three further cases are described.

DISCUSSION

The aetiology of non-surgical spinal cord infarction is not always evident, but is commonly associated with atherothrombosis. There are often delays in making a diagnosis, but early recognition and prompt treatment of spinal cord infarction is essential. Long-term functional outcomes are often poor and typically reflect the severity of initial presentation. This case series is unique as it has one of the longest follow-up periods described in the literature.

Idiopathic cervical cord infarction in a young girl presenting with acute neck pain and flaccid paralysis: a case report

INTRODUCTION

Spinal cord infarction (SCI) is a rare disease representing nearly 1% of all strokes with a wide variety of symptoms at presentation. SCI diagnosis is very challenging owing to its low incidence and the variety of symptoms, and could be misdiagnosed with neuromyelitis optica spectrum disorders (NMOSD).

CASE PRESENTATION

We describe the case of an 18-year-old girl who presented to the emergency department with acute neck pain and flaccid paralysis of the left upper and lower extremities. Few hours later, she developed apnea and was endotracheally intubated. Brain MRI was normal but spinal cord MRI revealed non-enhancing longitudinal abnormal high T2 signal intensity extending from C1 to C5. The patient underwent steroid therapy with methylprednisolone (1 g daily for 7 consecutive days) combined with physiotherapy. She was extubated after 3 weeks and discharged after 30 days of hospitalization with a muscle force of 4/5 in her left extremities.

DISCUSSION

Idiopathic SCI in adolescence is a rare but often devastating disorder with unknown pathophysiology, however, some specific conditions in adolescent such as mechanical stresses on the immature spine can be considered as risk factors for SCI development. Early diagnosis and treatment can improve outcomes in SCI.

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.

Spinal Cord Infarction Thrombolysed at Seven Hours: A Case Report and Review of Literature

We report a case of acute spinal cord infarction treated with intravenous (IV) thrombolysis at seven hours from symptom onset. Nineteen previously thrombolysed cases are reviewed. The patient underwent a clinical assessment, followed by an MRI of the spine. He was thrombolysed with a recombinant tissue plasminogen activator. Neurological severity was assessed at presentation and 24 hours using the National Institute of Health Stroke Scale (NIHSS), and disability at three months was evaluated using a modified Rankin scale (mRS). A middle-aged man presented with acute-onset paraplegia (NIHSS 9). MRI with T2-weighted sagittal, axial, and diffusion-weighted images showed hyperintensity from D10 to LI vertebral levels. He was thrombolysed at 428 minutes, leading to mild clinical improvement at 24 hours (NIHSS 7). At three months, he could walk with support (mRS 3). Nineteen cases of acute spinal cord infarction treated with IV thrombolysis have been reported. Clinical outcome at three months is available for 16 patients: seven (44%) had a good outcome (mRS 0-2); this is the first reported case of spinal cord infarction treated with thrombolysis at seven hours. Clinical trials to confirm the efficacy and safety of thrombolysis in spinal cord infarcts are needed.

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.

Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors

OBJECTIVE

The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented.

MATERIAL AND METHODS

Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time.

RESULTS

A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF.

CONCLUSION

Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.

A Rare Case of Cardioembolic Spinal Stroke in a Young Female: Case Report

Spinal cord infarction (SCI) is a rare neurovascular disorder often presented with acute spinal cord syndrome. The diagnosis is generally made clinically, with appropriate neuroimaging to confirm the diagnosis and exclude other causes. We present an unusual case of a 48-year-old woman with no relevant past medical history, admitted with acute paraparesis and a spinal cord infarct on magnetic resonance imaging. A thorough investigation revealed asymptomatic unknown heart failure secondary to hypertrophic cardiomyopathy, suggestive of a cardioembolic etiology. The patient was treated with anticoagulation and improved significantly with physical rehabilitation.