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

Anterior Spinal Artery Syndrome Due to Fibrocartilaginous Embolism-Case Report and Treatment Options

Acute occlusion of the anterior spinal artery and subsequent spinal ischemic infarction leads to anterior spinal artery syndrome characterized by back pain and bilateral flaccid paresis with loss of protopathic sensibility. As a rare cause fibrocartilaginous embolism has been described and is associated with sports or unusual strain.Following gymnastic exercise the day before symptom-onset, a 11 years old girl presented with neck pain, paresis of arms and legs, and impaired deep tendon reflexes. She was unable to lift her arms, grasp, stand, walk and had urinary incontinence. Magnetic resonance imaging revealed a longitudinal T2 hyperintense signal in the anterior spinal cord from C3 to C6 with accompanying bilateral diffusion restriction involving gray matter bilaterally at the level of C4 and C5 and unilaterally at the level of C3/4. The adjacent annulus fibrosus of the intervertebral disc showed a fissure without disc protrusion. Treatment with prednisolone and enoxaparin was started within 12 hours of symptom-onset and continued over 6 days and 8 weeks, respectively. After 2 months, her motor function gradually improved, spinal imaging showed persistent T2 signal hyperintense defects at the level of C4/5. After 5 months, there was only slight impairment affecting elevation and abduction of the right arm.Following physical exercise, the patient suffered from acute anterior spinal cord ischemia with imaging findings in line with a presumed fibrocartilaginous embolism. Unlike most cases, our patient showed almost complete recovery following treatment with prednisolone and enoxaparin. We speculate that the positive outcome is related to rapid treatment initiation.

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.

A case of spinal cord infarction presenting with unilateral C5 palsy

A 75-year-old man developed sudden-onset tetraparesis preceded by chest pain. MRI of the cervical spine on the day of onset showed no abnormalities. Although his motor symptoms improved gradually, the weakness of the muscles innervated by the C5 nerve root persisted. Sensory and autonomic deficits were detected on an additional neurological examination, and follow-up MRI eight days after onset revealed spinal cord infarction at the right anterior horn at C3-C4. This case suggests that motor symptoms mimicking a radiculopathy could be present during the course of spinal cord infarction.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

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.

Noniatrogenic spinal cord ischemia: A patient level meta-analysis of 125 case reports and series

Background:

Guidelines are needed to manage spinal cord infarctions. Here, we evaluated the incidence of noniatrogenic spinal ischemia, focusing on the spinal levels involved, and the relative efficacy of different management strategies.

Methods:

We performed a meta-analysis of 147 patients who sustained noniatrogenic spinal cord ischemia within the past 10 years. The most common causes of injury were idiopathic (i.e., 47% medical/surgery-related) followed by systemic/chronic conditions (23.6%) and aortic vascular pathology (20%). Postdiagnostic treatment options included rehabilitation in 53.7% of patients, while steroids (35.37%), antiplatelets aggregates (30.61%), and anticoagulation (18.37%) were also used.

Results:

Traumatic causes of spinal cord ischemia were associated with worse outcomes, while those without a clear diagnosis despite extensive work-up had better results. At discharge, patients managed with cerebrospinal fluid (CSF) drainage had significant improvement (P = 0.04), while other therapies were not effective. Notably, ischemia mostly occurring between the T4 and T7 levels and was associated with the worst outcomes. In this thoracic “watershed” region, thoracic cord ischemia was most likely attributed to an increased susceptibility toto cord under-perfusion in this region (P < 0.05).

Conclusion:

This meta-analysis revealed a variety of etiologies for noniatrogenic typically T4-T7 spinal cord ischemia. Several different treatment strategies may be utilized in this patient population, including CSF drainage, blood pressure elevation, corticosteroids, antiplatelets/anticoagulants/thrombolytics, mannitol, naloxone, surgical revascularization, hyperbaric oxygen, and systemic hypothermia.

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.

Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome

Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl's eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.

Clinical Presentation and Causes of Non-traumatic Spinal Cord Injury: An Observational Study in Emergency Patients

Introduction: Diagnosing non-traumatic spinal cord injury (NTSCI) is often challenging. However, clear discrimination from non-spinal pathologies, e.g., "myelopathy-mimics" (MMs), is critical in preventing long-term disability and death. In this retrospective study we (1) investigated causes of NTSCI, (2) identified clinical markers associated with NTSCI and (3) discuss implications for NTSCI management. Methods: Our sample consisted of 5.913 consecutive neurological and neurosurgical patients who were treated in our emergency department during a one-year period. Patients with a new or worsened bilateral sensorimotor deficit were defined as possible NTSCI. We then compared clinical and imaging findings and allocated patients into NTSCIs and MMs. Results: Of ninety-three included cases, thirty-six (38.7%) were diagnosed with NTSCI. Fifty-two patients (55.9%) were classified as MMs. In five patients (5.4%) the underlying pathology remained unclear. Predominant causes of NTSCI were spinal metastases (33.3%), inflammatory disorders (22.2%) and degenerative pathologies (19.4%). 58.6% of NTSCI patients required emergency treatment. Presence of a sensory level (p = <0.001) and sphincter dysfunction (p = 0.02) were the only significant discriminators between NTSCI and MMs. Conclusion: In our study, one-third of patients presenting with a new bilateral sensorimotor deficit had NTSCI. Of these, the majority required emergency treatment. Since there is a significant clinical overlap with non-spinal disorders, a standardized diagnostic work-up including routine spinal MRI is recommended for NTSCI management, rather than an approach that is mainly based on clinical findings.

[Spinal cord ischemia]

Spinal cord ischemia is a rare disease with a poor prognosis. As with cerebral ischemia, spinal infarction typically presents with sudden symptom onset and variable clinical manifestation (depending on the lesion location). The majority of spinal ischemias occur in the supply territory of the anterior spinal artery, involving the anterior and middle third of the myelon. The most common cause of spinal ischemia is an arterial vessel occlusion, although venous ischemia and hypotensive watershed infarcts may also occur. Magnetic resonance imaging (MRI) represents the modality of choice for diagnosis of spinal cord 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.

New Model of Ventral Spinal Cord Lesion Induced by Balloon Compression in Rats

Despite the variety of experimental models of spinal cord injury (SCI) currently used, the model of the ventral compression cord injury, which is commonly seen in humans, is very limited. Ventral balloon compression injury reflects the common anatomical mechanism of a human lesion and has the advantage of grading the injury severity by controlling the inflated volume of the balloon. In this study, ventral compression of the SCI was performed by the anterior epidural placement of the balloon of a 2F Fogarty's catheter, via laminectomy, at the level of T10. The balloon was rapidly inflated with 10 or 15 μL of saline and rested in situ for 5 min. The severity of the lesion was assessed by behavioral and immunohistochemical tests. Compression with the volume of 15 μL resulted in severe motor and sensory deficits represented by the complete inability to move across a horizontal ladder, a final Basso, Beattie and Bresnahan (BBB) score of 7.4 and a decreased withdrawal time in the plantar test (11.6 s). Histology and immunohistochemistry revealed a significant loss of white and gray matter with a loss of motoneuron, and an increased size of astrogliosis. An inflation volume of 10 μL resulted in a mild transient deficit. There are no other balloon compression models of ventral spinal cord injury. This study provided and validated a novel, easily replicable model of the ventral compression SCI, introduced by an inflated balloon of Fogarty´s catheter. For a severe incomplete deficit, an inflated volume should be maintained at 15 μL.

A Case of Paradoxical Embolism Causing Anterior Spinal Cord Syndrome and Acute Myocardial Infarction Following the Intradiscal Oxygen-Ozone Therapy

We report a case of a 66-year-old female who burst into flaccid paralysis of the lower extremities, accompanied by loss of pain and temperature sensation below T4 level, during an oxygen–ozone injection for disc herniation. Half an hour later, she suffered from chest pain. Magnetic resonance imaging (MRI) showed long segment hyperintensity in the thoracic spinal cord from T2 to 10 level on sagittal T2-weighted images (T2WI). The electrocardiogram (ECG) showed ST-segment elevation in V1–V6 leads. She was diagnosed with spinal cord infarction and ST-elevation myocardial infarction (STEMI). Transthoracic echocardiography with saline contrast showed existence of a large patent foramen ovale (PFO) correlating with the detection of massive microbubbles in the left atrium. We discuss the potential role of paradoxical embolism in spinal cord infarction and myocardial infarction.

Anterior spinal cord syndrome-"owl's eye sign"

Magnetic resonance imaging revealing abnormally high signal intensity in the thoracic cord, extending from T5 to T10 on a sagittal T2‐weighted image (Figure 1A). An axial T2‐weighted image showing “owl's eye sign” involving central‐anterior cord (Figure 1B), which was consistent with anterior spinal cord syndrome.

Herpes Simplex Virus Type 2 Myelitis: Case Report and Review of the Literature

Non-traumatic myelopathies can result from a wide spectrum of conditions including inflammatory, ischemic, and metabolic disorders. Here, we describe the case of a 60-year old immunocompetent woman who developed acute back pain followed by rapidly ascending flaccid tetraparesis, a C6 sensory level, and sphincter dysfunction within 8 h. Acyclovir and steroids were started on day 2 and herpes simplex virus type 2 (HSV-2) was confirmed by polymerase chain reaction in cerebrospinal fluid. Magnetic resonance imaging revealed a bilateral anterior horn tractopathy expanding from C2 to T2 and cervicothoracic cord swelling. Screening for paraneoplastic antibodies and cancer was negative. Neurophysiology aided in the work-up by corroborating root involvement. Recovery was poor despite early initiation of antiviral treatment, adjuvant anti-inflammatory therapy, and neurorehabilitation efforts. The clinical course, bilateral affection of the anterior horns, and early focal atrophy on follow-up magnetic resonance imaging take a necrotizing myelitis potentially caused by intraneuronal spread of the virus into consideration. Further, we summarize the literature on classical and rare presentations of HSV-2 myeloradiculitis in non-immunocompromised patients and raise awareness for the limited treatment options for a condition with frequent devastating outcome.